Synopsis On the evening of 19July 1997 an explosion and fire occurred on board the tanker PETROLAB while the crew was washing cargo oil tanks in preparation for loading cargo. The ship's owner was killed and three members of the crew, one of whom later died in hospital, were injured by the explosion. The ensuing on-board fire subsequently spread to the government wharf. The combined efforts of two Canadian Coast Guard vessels and several shore-based fire departments were required to bring the fire under control. As a precaution, the town of St.Barbe was partially evacuated. Both the ship and the government wharf were destroyed before the fire was fully extinguished some 63 hours later. No pollution was reported as a result of the fire. The Board determined that the explosion occurred due to an accumulation of gasoline vapour in the after cofferdam, 'tween-deck space, and engine-room. The source of ignition was not determined. Factors contributing to the explosion were: the owner's and crew's ignorance of tanker safe working practices; the improvised and unsafe working practices devised to replace a tank-stripping system that had been inoperable for at least 10 years; the fact that there was no safety management system in place; the use of the cofferdam, which was open both to the 'tween-deck and the engine-room, as a slop tank; the use of pumping equipment uncertified for use in a hazardous environment; the fact that the mechanical ventilation for the cofferdam and 'tween-deck area was not used and no atmospheric monitoring was carried out; and the presence of substandard electrical equipment and fittings in the engine-room. 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel 1.2 History of the Voyage 1.2.1 Before the Explosion 1.2.2 After the Explosion 1.3 Injuries to Persons 1.4 Damage 1.4.1 Damage to the Vessel 1.4.2 Damage to the Government Wharf 1.4.3 Damage to the Environment 1.5 Certification 1.5.1 Vessel 1.5.2 Personnel 1.6 Personnel History 1.6.1 Crew Certification and Experience 1.6.2 Crew Training 1.6.3 Crew Work Practices 1.6.4 Management Oversight and Chain of Command 1.7 Weather 1.8 Activities and Conditions Creating a Danger of Explosion 1.9 Sources of Ignition 1.9.1 Build-up of Static Electricity 1.9.2 The Portable Centrifugal Pump 1.9.3 Engine-room Electrical Equipment 1.10 Firefighting 1.10.1 Emergency Preparedness 1.10.2 Shipboard Firefighting Capability 1.10.3 Shore-based Firefighting Capability 1.10.4 Canadian Coast Guard Firefighting Capability 1.11 Condition of the Vessel's Cargo-handling Equipment 1.12 Oily Water Separator 1.13 Engine-room Escape Door 1.14 'Tween-deck Arrangement 1.15 Inspection of the Vessel by Transport Canada 1.16 Use of the Government Wharf by Passenger Ferries and Tankers 1.17 Fire Safety in Canadian Ports and Harbours 1.18 Safety and Emergency Preparedness in Canadian Ports 1.19 Guidelines on Risk Assessment and Emergency Plans for Ports 2.1 Crew Training 2.2 Management Oversight 2.3 Chain of Command 2.4 Explosive Environment and Sources of Ignition 2.5 Local Firefighting 2.6 Condition of the Vessel's Cargo-handling Equipment 2.7 Oily Water Separator Exemption 2.8 Engine-room Escape Door 2.9 Use of the Government Wharf by Passenger Ferries 2.10 Transport Canada Inspections 2.10.1 Construction 2.10.2 Bilge-pumping Arrangements 2.10.3 Cargo-pumping Arrangements 2.10.4 Emergency Equipment 2.10.5 Assessment of the Crew's Competence 3.1 Findings 3.2 Causes 4.1 Action Taken 4.1.1 Cargo-pumping Systems 4.1.2 Petroleum Tanker Endorsements 4.1.3 Firefighting in Canadian Ports 4.1.4 Public Safety 4.1.5 Transport Canada Inquiry Appendix A - Sketch of the Occurrence Area Appendix B - Drawings Appendix C - Graph of Oxygen/Oil Vapour Flammability Appendix D - Photographs Appendix E - Glossary Appendix A - Sketch of the Occurrence Area Appendix B - Drawings Appendix C - Graph of Oxygen/Oil Vapour Flammability Appendix D - Photographs Appendix E - Glossary 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The motor tanker PETROLAB was a steel-hulled product tanker built in 1962 in Norway, with accommodation and machinery spaces aft and six pairs of cargo oil tanks (COTs) numbered 1 through 6 (port and starboard) from forward. The main deck was enclosed by a 'tween-deck space, which housed the cargo-pumping equipment and pipelines. The 'tween-deck was also used to store cargo hoses, equipment, and lube oil products, which were sold at various ports. An after cofferdam was positioned at frames 18 to 21 between the engine-room and No.6 COTs. There were dedicated slop tanks (7.97m3) between frames 19 and 21, at the bottom of the cofferdam. An engine room escape door was located in the forward port engine room bulkhead giving access to the cofferdam and ladders to the main deck. 1.2 History of the Voyage 1.2.1 Before the Explosion In May 1997 the PETROLAB was chartered by Ultramar Canada Inc. to tranship refined petroleum products from its St.Barbe terminal to ports on the Lower North Shore of Quebec. The vessel underwent an annual inspection by Transport Canada (TC) Marine Safety and a pre-charter survey by Ultramar during May, before beginning operations for the 1997 season. Gasoline and diesel oil were normally carried on each trip, and the vessel was equipped with cargo pumps dedicated to pumping each. From time to time, due to the unavailability of product at St.Barbe or the requirements of the discharge terminals, homogeneous cargoes would be carried. On 16July 1997, at 1355, the PETROLAB departed St.Barbe with a full load of gasoline bound for Saint-Augustin, Quebec.[3] After discharging her full cargo and ballasting Nos.3 and 4 COTs, the vessel departed Saint-Augustin at 0700 on July 18 and arrived back in St.Barbe at 1400 the same day. Because another tanker was discharging, the PETROLAB was secured on the opposite side of the wharf, at the berth normally used by the Quebec North Shore ferry NORTHERN PRINCESS. During a previous trip in 1997, a cargo of diesel oil had been loaded after carrying a full load of gasoline. No flushing oil had been used or tank washing carried out and, as a result, the flash point of the diesel oil was reportedly below specifications when discharged. It was learned on July 18 that a full cargo of stove oil was to be loaded. To avoid a re-occurrence of the low flash point problem, the owner and first mate decided to wash Nos.1, 2, 5, and 6 COTs with seawater. The accepted tank washing procedure on the PETROLAB was for a mate to enter the tank wearing a Scott air pack and trailing a fire hose. After the tank was hosed down, the remaining un-pumpable residue would be scooped into buckets and dumped into the cofferdam (referred to by the crew as the slop tank). Tank washing began after noon onJuly 19, but trouble was encountered maintaining suction while stripping tanks with the main cargo pumps. The vessel's fixed tank-stripping system had been out of service for at least 10 years and was not available. As a result, tank stripping was attempted using a rented diesel-driven pump situated on the dock. When this failed to pick up suction, a Honda portable gasoline-driven pump was rigged on deck, with the suction hose in the tank being washed and the discharge hose running aft through the 'tween-deck escape hatch (See figure 1, page 9). It was reported that the hose extended approximately one metre into the hatch, and was not grounded. The cargo slops, a mixture of gasoline and water, fell through the 'tween-deck into the cofferdam, a distance of 4.5metres. During this time, no atmospheric monitoring was conducted in the COTs, 'tween-deck, cofferdam, or deck work areas. Nos.1 and 2 COTs were cleaned in this manner without incident and, in the early evening, attention was turned to No.5 COTs. At approximately 2000, the first mate had just placed the suction hose into the slops in No. 5 COT when his Scott air pack low air pressure alarm sounded. He left No.5 port COT and was standing next to the 'tween-deck escape hatch with the owner and a deck-hand. A rumbling sound was heard from the 'tween-deck area, followed by an explosion. The owner, who was looking into the 'tween-deck escape hatch, was thrown over the port railing into the harbour by the force of the explosion. The first mate and deck-hand, standing one metre away, were thrown to the deck and were burned by the explosion. Earlier in the afternoon, the chief engineer and second engineer had been employed changing a cargo system valve within the 'tween-deck, in the vicinity of No.2 COTs. Work on the valve was completed by 1930, after which the engineers had their evening meal. The second engineer then went to his cabin for a shower. The second engineer heard the chief engineer enter the engine-room by the entrance on the port side of the accommodation. Shortly afterward, an explosion occurred, immediately followed by the sound of the halon release alarm in the engine-room. The Board of Steamship Inspection (BSI) had granted the vessel an exemption from the requirement to have an engine-room oily water separator on board. It was reported that it was not uncommon for the engine-room bilges to be pumped into the cofferdam for disposal ashore along with the COT slops. During the post-occurrence examination of the engine-room, a portable direct current (DC) electric bilge pump was found in the bilge, forward of the main engine. A plastic discharge hose led from this pump toward the engine-room escape door. The door was found in the open position after the fire. 1.2.2 After the Explosion Following the explosion, the injured first mate and deck-hand of the watch made their way to the wharf. The second engineer left his cabin and exited the accommodation to the deck outside on the starboard side. There he met the injured chief engineer and assisted him from the vessel to the wharf. The master, who had been on the bridge at the time of the explosion, made his way to the main deck where he shut down the portable pump before disembarking to the wharf and asking the Ultramar agent to call the fire department and an ambulance. The second mate, who had been on the dock at the time of the explosion, boarded the vessel and put out several small fires on deck with a portable fire extinguisher. In an attempt to rescue the owner from the water, the second engineer, master and second mate reboarded the vessel. Assisted by the master and second mate, the second engineer climbed down the ship's side with a life ring. The rescue attempt was unsuccessful but the second engineer managed to secure the owner's body with a rope attached to the ship's railing. The ensuing fire was limited to ship's stores burning in the 'tween-deck until, some two to three hours after the explosion, the paint on the outer hull began to burn and spread fire to the creosote-impregnated dock pilings. Out of concern that the fire might spread to the adjacent tank farm, the pipelines to the dock were flushed with seawater and part of the town of St.Barbe was evacuated. On July 20,at 0100, the CCGS HOOD arrived and began firefighting on the dock. The mooring lines of the PETROLAB burned through and, at 0500, the vessel drifted across the harbour and grounded 0.15 mile from the wharf, where local firefighters applied foam. The CCGS SIR WILFRED GRENFELL arrived at 0930 and fought the dock fire using water cannon and foam until the fire on the wharf was declared out at about 1100 onJuly22. 1.3 Injuries to Persons None of the crew was wearing protective flame-retardant clothing at the time of the explosion. The owner, who was in the path of the explosion and flame front as it exited the 'tween-deck escape hatch, was thrown over the port railing into the water. His body was recovered from the water early the next morning. He suffered third-degree burns over 50percent of his body. The first mate and deck-hand, who were standing on deck next to the owner, suffered first- and second-degree burns to the hands and face. As well, the deck-hand suffered a dislocated shoulder when he fell while climbing onto the dock. The chief engineer, who was in the engine-room at the time of the explosion, suffered third-degree burns to 50percent of his body. He died in hospital two weeks later. 1.4 Damage 1.4.1 Damage to the Vessel As a result of the explosion, the deck house structure was distorted and its port holes shattered. The vessel was damaged extensively by the fire. The accommodation was completely gutted and the aluminium superstructure extensively deformed. All combustible materials in the 'tween-deck were destroyed and the structure of the 'tween-deck was extensively damaged. There is no indication of fire in the engine-room although heat and smoke damage from the fire above was present on the upper portions, particularly the deckhead. The COTs were not breached during the explosion and fire. Since the fire, the PETROLAB has been declared a constructive total loss and has been sold. 1.4.2 Damage to the Government Wharf As a result of the fire, the government wharf, pipelines, and ferry ramp were completely destroyed. 1.4.3 Damage to the Environment There was no damage to the environment. 1.5 Certification 1.5.1 Vessel The PETROLAB was certified by TC in accordance with the requirements for a vessel of her type in the trade in which she was engaged. She was exempted from carrying an engine-room oily water separator. The vessel had been built to Det Norske Veritas standards, but was not classed with a classification society at the time of the explosion. 1.5.2 Personnel The master and officers held valid Canadian certificates for the nature of the voyages undertaken.[4] Only the first mate and chief engineer held petroleum tanker endorsements. 1.6 Personnel History 1.6.1 Crew Certification and Experience The master of the PETROLAB had no previous experience on board oil tankers and had been in command of the PETROLAB since September 1996. His previous experience with transporting petroleum products consisted of four seasons as master of a tug towing oil barges in James Bay. At the time of the occurrence, he held a Canadian Master Home Trade certificate of competency but he did not have a petroleum tanker endorsement. He had been employed in various capacities as a ship's officer since the mid-1960s. The first mate held an Ocean Navigator LevelII (ONII) certificate of competency. He had been employed on board the PETROLAB for 10 years, starting as a deck-hand and working his way up to mate. He held a petroleum tanker endorsement (Level I) but had not taken a tanker safety course. The endorsement was issued based on tanker time served. All of his qualifying tanker sea service had been aboard the PETROLAB. The chief engineer held a Canadian Third Class Engineer (motor) certificate of competency and had been employed on board the PETROLAB since 1992. He held a petroleum tanker endorsement (levelII) but had not taken a tanker safety course, the endorsement having been issued based on tanker time served. Like the first mate, the chief engineer's entire qualifying tanker sea service had been aboard the PETROLAB. The vessel's owner held no certificate of competency and had no formal training in marine emergency duties (MED) or petroleum tanker safety. He had been employed many years ago on coastal passenger vessels as an uncertificated crew member. All of the certificated crew (officers) had been trained in shipboard firefighting, as required by the Canadian Marine Certification Regulations. 1.6.2 Crew Training None of the crew had taken a petroleum tanker safety course and only two crew members, the first mate and the chief engineer, held petroleum tanker endorsements, which they had obtained on the basis of their length of service on board. There was no formal orientation/training policy or procedure for new employees. New crew members would be shown their duties by old hands who were familiar with the vessel. At the time of the explosion on the PETROLAB, it was not mandatory under Canadian regulations for any of the officers or crew to have taken a petroleum tanker safety course. New Canadian regulations complying with the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) came into force 30 July 1997 at which time only Masters and Chief Mates were required to have taken a tanker safety course. Chief and second engineers were granted a two-year transition period until 30 July 1999 before they are required to have taken a course. Other officers and crew will continue to be granted tanker endorsements (levelI)--without a formal course or TC examinations--by serving 3 months on board tankers. There is no record of boat or fire drills being conducted on the PETROLAB during the 1997 season. 1.6.3 Crew Work Practices Some non-standard work practices and procedures had developed over time, and came to be accepted on board the PETROLAB, including the following: Entering a cargo tank with a Scott air pack to wash tanks. Entering a cargo tank without proper atmospheric monitoring of the tank. Using an ungrounded fire hose to wash cargo tanks containing flammable vapours. Using a pump not designed for use in a hazardous location to transfer slops. Use of the open aft cofferdam as a slop tank. Allowing slops to free-fall through the 'tween deck into the cofferdam. Not using the 'tween deck /cofferdam exhaust fans during the slop transfer. No atmospheric monitoring was conducted during the slop transfer. None of the crew had formal training in confined space entry. The crew were not familiar with the Workplace Hazardous Material Information System (WHMIS) and its associated hazardous material data sheets describing the health dangers from the cumulative carcinogenic effects of benzene in petroleum products. The engine-room escape door was not kept closed at all times. The use of an uncertified submersible bilge pump in the engine-room for pumping engine-room bilge slops to the cofferdam. 1.6.4 Management Oversight and Chain of Command The owner had operated the PETROLAB since 1991 and had been using the vessel to supply his own petroleum tank farms on the Labrador Coast. He did not have a formal safety management system in place for the vessel, but relied on the crew (in particular the first mate) to operate the vessel in a safe manner. Problems existed with the chain of command on board the PETROLAB. Because the first mate had been on board for many years, the owner often communicated shipboard business directly with the mate. As a result, on the PETROLAB decisions were often made without the master's knowledge or participation. This situation led to friction between the master and first mate. The master had expressed his displeasure to the owner concerning this situation and, two weeks before the explosion, the first mate had left the vessel. He had returned to his duties on board three days before the explosion. 1.7 Weather The weather on July 19 had been rainy; thunder and lightning during the morning and early afternoon was followed by a clearing spell. At the time of the explosion winds were calm from the northeast and the sky had become overcast again. The air temperature was approximately 14 degrees Celsius. The master reported that just before the explosion he had seen lightning to the south, but this was not observed by the other people interviewed. 1.8 Activities and Conditions Creating a Danger of Explosion The majority of the crew members had acquired their experience of tanker operations solely aboard the PETROLAB. There was no formal training scheme on board and the work practices and procedures in place had been developed through on-the-job training. Some of these procedures created unsafe conditions. These unsafe work practices had been passed on to new crew members who, lacking formal petroleum tanker training, did not recognize the inherent dangers of conducting tanker operations in the manner in which they were conducted. None of the PETROLAB crew had taken a petroleum tanker safety course. Only the first mate and the chief engineer held petroleum tanker endorsements and these had been issued solely on the basis of the time they had served aboard the PETROLAB. The activities and conditions creating a danger of explosion were: COTs were washed down by members of the crew wearing breathing apparatus and using a fire hose that was not grounded. The resulting cargo slops were transferred to the cofferdam by a portable pump that was not designed for use in this type of operation. The slops were discharged into the cofferdam immediately forward of the engine-room instead of into the dedicated slop tanks. The slops were allowed to free-fall into the cofferdam from an uncertified and ungrounded rubber hose, creating vapour concentrations in excess of the lower explosive limit (LEL) and a static electricity hazard. The exhaust fans for the cofferdam and 'tween-deck space were not in use. The engine-room escape door was unsecured during the slop transfer. 1.9 Sources of Ignition Several potential sources of ignition were present in the explosive environment that resulted from the vessel's non-standard cargo tank washing procedures. 1.9.1 Build-up of Static Electricity The static electrical charge that builds up during the handling of gasoline on board tankers presents a potential source of ignition. Certain operations can give rise to accumulations of an electric charge that may be released suddenly in electrostatic discharges--with sufficient energy to ignite flammable gasoline/air mixtures. The operations that can cause static charges to accumulate, and the characteristics of static charge accumulation on petroleum cargoes, are well understood by the tanker industry. When gasoline is mixed with water, a static charge is generated between the two. Both speed and turbulence of flow of the gasoline and water mixture will affect the charge that accumulates. The damage to the Honda pump impeller (TSB Engineering Lab report No. LP 115/97)[5] would have contributed considerable turbulence to the flow of the gasoline and water tank washing slops as it passed through the pump. The discharge hose of the pump, which was of smaller diameter than intended, would have increased the speed of the gasoline and water mixture through the hose. As gasoline is pumped through the steel pipelines that are part of the ship's installations, static charges accumulate between the gasoline and the pipe. The charge left on the pipe will quickly pass to the structure of the ship and dissipate into the sea and thereby to ground. When rubber hoses are used to pump gasoline, the accumulated charge in the hose does not dissipate to ground. Bonding wires (usually built into the hose) are used to connect the steel flanges of the hose to one another and to the ship's structure, allowing static charges to dissipate to ground. The discharge hose leading into the 'tween-deck space on the PETROLAB was not grounded and would have presented another source of static electricity. When cargo transfer hoses are tested, a continuity test is normally conducted to ensure that the internal bonding wire is intact and that there is electrical continuity between both ends of the hose. No hose test certificate was available for the portable pump discharge hose in use at the time of the explosion, nor was there any record of continuity tests being conducted on any other hoses (including cargo discharge hoses) on the PETROLAB. Oil splashing or spraying also results in an accumulation of static charge. Oil droplets striking solid surfaces such as bulkheads result in a charge accumulation between the oil and the bulkhead. Oil that is loaded through flexible hoses inserted into tanks will produce a considerable amount of splashing and spraying as the liquid falls to the bottom of the tank, resulting in a statically charged mist in the tank. On the PETROLAB, the Honda pump discharge hose extended only one metre into the 'tween-deck escape hatch; from there, the gasoline and water mixture sprayed down into the cofferdam, striking bulkheads, gratings, and pipework as it fell. 1.9.2 The Portable Centrifugal Pump The portable centrifugal pump being used to transfer tank washing slops was a Honda model WB30X. The operating manual for this pump gives several specific warnings: [in the Introduction] WARNING This Honda pump is designed to give safe and dependable service if operated according to instructions. Read and understand the Owners Manual before operating the pump. Failure to do so could result in personal injury or equipment damage. [under Safety Instruction] WARNING For safety, never pump flammable or corrosive liquids such as gasoline or acid. Also to avoid pump corrosion, never pump sea water, chemical solutions, or caustic liquids such as used oil, wine, or milk. [under Safety Instruction] WARNING Gasoline is extremely flammable and is explosive under certain conditions. Do not smoke or allow flames or sparks in the refuelling area or where gasoline is stored. Do not overfill the tank. After refuelling, make sure the tank cap is closed and properly secured. At the time of the explosion, the pump was being used to pump a mixture of gasoline and seawater; substances specifically warned against by the pump manufacturer. The fuel cap on the pump's tank was not in place and the fuel tank was nearly full, indicating that it had been filled recently. The TSB Engineering Laboratory inspection found that the cap was not blown off by an explosion. Internal inspection of the pump revealed a damaged impeller that caused an imbalance and vibration when the pump was running. Earlier in the day, the pump had been mounted on rubber tires to prevent it from walking around the deck while it was running, but at the time of the explosion the pump was sitting directly on deck. The Safe Working Practices Regulations state: In any working area where flammable gas vapours or dust is present in the atmosphere, no person shall use any equipment or materials that are spark producing.[6] The pump was not equipped with an exhaust spark arrester and was operating in the presence of gasoline fumes. 1.9.3 Engine-room Electrical Equipment Much of the electrical equipment in the engine-room was not intrinsically safe or certified for use in a hazardous area, and several possible sources of sparks or open flame were present in the engine-room at the time of the explosion.[7] Post-occurrence examination of the engine-room found that covers were missing from several light fixtures and lights were jury-rigged with substandard wiring. A portable DC bilge pump was used to transfer oily waste from the engine-room bilges to the cofferdam through a non-grounded plastic discharge hose. The pump wiring was jury-rigged to the port generator starter motor. There was an oil-fired domestic hot water boiler in the engine-room. The port ship's service generator, located adjacent to the escape door, was running and supplying power to the vessel at the time of the explosion. 1.10 Firefighting 1.10.1 Emergency Preparedness The wharf at St. Barbe served both oil tankers and passenger vessels on a regular basis, but none of the local volunteer fire departments responding to the fire had training in shipboard firefighting. The harbour facilities in St. Barbe had been turned over to the Province of Newfoundland on 1 April 1997 as part of TC's port divestiture program. When transferring a port to new owners, TC does not ensure that the owners have contingency plans in place to deal with emergencies. The terminal operator, Ultramar, did have a contingency plan in place for an oil spill at the dock or a fire at the tank farm; however, the terminal supervisor had not been given formal training in firefighting. As a result, Ultramar was relying on the local fire department, which did not have the equipment (foam) to fight petroleum fires or the experience and training to fight shipboard fires and contain them at an early stage. 1.10.2 Shipboard Firefighting Capability The vessel's firefighting equipment and its installation met regulatory requirements. On board equipment included: a main electrically driven fire pump in the engine-room, a mechanical foam system in the 'tween-deck, a CO2 system for the COTs, and a halon system for the engine-room. The PETROLAB, as a vessel under 45.7 m long, was not required by regulation to be equipped with an emergency fire pump or emergency generator. At the time of the explosion, the ship's service generator failed. As the vessel was not equipped with an emergency generator, neither the fire pump nor the 'tween-deck foam system could be operated. The actuating handle for the engine-room halon system was located in the deck-house where the force of the explosion distorted the bulkhead and the mechanical actuating system, causing the release of the halon into the engine-room. The halon helped to suppress the ensuing fire and to protect the engine-room and cofferdam from further damage. Immediately after the explosion, the second mate put out several small fires on deck with a fire extinguisher, then joined the remaining crew who had gathered on the wharf. No attempt was made to re-enter the engine-room to restart the ship's service generator and put the fire pump on line. The vessel was not fitted with an international shore connection, and the vessel's fire main could not be charged from a source on shore. The ship's Scott air pack bottles were empty, having been used during the tank washing operations. The vessel's firefighting system was disabled. The Royal Canadian Mounted Police (RCMP) sent the crew away from the scene to a local hotel. Fire wires, to which a towing vessel could quickly make fast and so tow her away from the government wharf, had not been rigged at the bow and stern of the vessel. 1.10.3 Shore-based Firefighting Capability In all, six local volunteer fire departments responded to the fire, arriving between 2015 and 2130 on July 19. At this time, the fire was still confined to the 'tween-deck area where stored lube oil and other consumable stores had caught fire. The master informed the fire chief of the local fire department of the previous cargo, the state of the vessel's tanks and the location of the fire. The fire departments were unfamiliar with fighting shipboard fires, especially oil tanker fires, and were reluctant to fight the fire in its early stages using water as they believed that water should not be applied to oil (tanker) fires. The Port au Choix fire department arrived with medium expansion foam at 2050 (about one hour after the explosion), but the foam was not applied to the fire which, at that point, was still limited to the area inside the vessel's 'tween-deck. No coordinated firefighting was conducted until the regional fire commissioner arrived in the early morning of July 20. After the ship's mooring lines burned through and she drifted across the harbour and grounded, the fire department applied foam and brought the fire under control from a position on shore. For two to three hours after the explosion, no effort was made by the ship's crew or the shore-based firefighters to fight the fire which, at that point, was limited to the 'tween-deck area. 1.10.4 Canadian Coast Guard Firefighting Capability The CCGS HOOD arrived on the scene early in the morning of 20 July and began fighting the dock fire. No fire wires had been rigged on the PETROLAB, which made it hazardous for the HOOD to attempt towing of the burning tanker from the dock. After the mooring lines burned through and the PETROLAB began drifting across the harbour, a small boat from the HOOD managed to get a line aboard the tanker and secure it to shore. At 0930 on 20 July, the CCGS SIR WILFRED GRENFELL arrived on the scene and began alternately fighting the dock fire with water cannon and trying to dismantle the dock to give better access to the seat of the fire. The CCG's firefighting efforts were coordinated with the shore-based units through the district fire commissioner. 1.11 Condition of the Vessel's Cargo-handling Equipment The condition of cargo pumps and piping systems is important for the safe operation of all oil tankers. Besides being used to discharge cargo, a tanker's pumping system may be used in damage and stability control situations resulting from flooding, and in cargo transfer operations to mitigate pollution resulting from accidents. As such, cargo-pumping systems on oil tankers are analogous to bilge-pumping systems on other vessels. Cargo-pumping systems on oil tankers vary considerably, but one consistent feature found on each is a stripping system with the ability to remove all possible cargo from the tanks. The PETROLAB was originally equipped with a vacuum stripping system to maintain suction on the cargo pumps, but at the time of the explosion the system had been inoperable for at least 10 years. As originally built, the PETROLAB was capable of stripping tanks using the main cargo pumps, with the tank washing slops being pumped directly through a fixed piping system to the dedicated slop tanks located between frames 19 and 21 at the bottom of the after cofferdam. Use of a portable pump was neither necessary nor desirable. Several years before the occurrence, the owner and the first mate had investigated the possibility of returning the stripping system to service, but inspection had revealed that it was extensively deteriorated; the system was blanked off permanently. It is unknown when the cofferdam started to be used as a slop tank, but the first mate indicated that it had been used to store slops before he first served aboard 10 years earlier. Post-occurrence inspection of the cargo piping system showed that a drain valve had been added to the main cargo line with a hose leading into the cofferdam. Such an arrangement by-passed the dedicated slop tanks, allowing the use of the cofferdam as storage for cargo slops. The cofferdam was open on top to the 'tween-deck and connected to the engine-room by an emergency escape door on the port side. With such an arrangement, vapour from the slops in the cofferdam could easily enter the 'tween-deck area, or if the engine-room escape door was opened, into the engine-room. Post-occurrence sounding of the cofferdam revealed that it contained 975 mm of liquid, 640 mm of which was water and 335 mm a mixture of hydrocarbons (see TSB Engineering Lab report No. LP 115/97). 1.12 Oily Water Separator Oily water separators are used on vessels to remove oil from bilge water before it is discharged overboard. They allow a vessel relative freedom to pump the bilges without fear of polluting surrounding waters. Under the Oil Pollution Prevention Regulations, all Canadian tankers of 150 gross tons and over are required to have a Canadian Oil Pollution Prevention (COPP) certificate, which requires, in part, that the vessel be equipped with an oily water separator for handling engine-room bilge slops. In 1993 the owner of the PETROLAB made application to the BSI for an exemption from the requirement to equip his vessel with an engine-room oily water separator. In his letter of application, he made a proposal to store engine-room bilge slops in the dedicated slop tanks located between frames 19 and 21. The BSI granted the exemption on 30 August 1993. One of the conditions attached to the exemption was that the engine-room bilge slops would be stored in the slop tanks and be pumped ashore as necessary. There is no record to indicate if, subsequent to that time, the dedicated slop tanks were used to store engine-room slops. Post-occurrence sounding of the dedicated slop tanks indicated that they were empty. It is known that the engine-room bilges were routinely pumped overboard when the vessel was at sea or into the cofferdam during extended stays in port. It is also known that, before and after this exemption was granted, the cofferdam was routinely being used as a slop tank. Normally, such transfers were handled by the first mate or the chief engineer. 1.13 Engine-room Escape Door On board oil tankers, special precautions are taken to ensure that no petroleum or petroleum vapour can enter the engine-room. Many tankers have pump rooms just forward of the engine-room, and special arrangements are used to seal piping, electrical and machinery penetrations through the bulkhead between the two spaces. On board the PETROLAB, an escape door was fitted in the forward engine-room bulkhead leading into the cofferdam, which was being used as a slop tank at the time of the explosion. Examination of the soot patterns on the door dogs indicates that it was unsecured at the time of the explosion. This escape door had been added to satisfy the regulatory requirement for a second means of escape from the engine-room when the vessel came under Canadian registry in 1983. TC Marine Safety approved the design, location and installation of the door. 1.14 'Tween-deck Arrangement The 'tween-deck arrangement on the PETROLAB was not a feature commonly found on oil tankers. The 'tween-deck contained the cargo pumps and piping equipment and performed the function of the pump room found on more conventional tankers. The International Convention for the Safety of Life at Sea (SOLAS) requires that pump rooms be equipped with mechanical ventilation.[8] Because the vessel was under 500 tons it did not have to comply with SOLAS regulations. The 'tween-deck on the PETROLAB was equipped with exhaust fans but, because petroleum vapours could be smelled on the bridge deck when they were running, the fans were not used. The fourth edition of the International Safety Guide for Oil Tankers and Terminals (ISGOTT) is the standard reference text used by tanker and terminal operators. It states that the pumproom should be kept continuously ventilated during cargo operations, and that ventilation should be continuous until access is no longer required or cargo operations have been completed.[9] There was no copy of the ISGOTT manual on board the PETROLAB, and the officers and crew were unfamiliar with the publication. 1.15 Inspection of the Vessel by Transport Canada When the PETROLAB came under Canadian flag in 1983, drawings of the cargo-pumping system were submitted to and approved by TC. Under current Canadian regulations, there is no requirement for the inspection of cargo pumps and pumping systems of oil tankers. In May 1997 the vessel underwent an annual inspection by TC in St. John's, Newfoundland. At the time of inspection, several lights in the engine-room were found to have covers missing and to have jury-rigged (non-standard) wiring. This situation was not treated as a deficiency. The cargo-pumping system was not inspected, nor was it required to be. The engine-room bilge-pumping system was only inspected every five years. The after cofferdam was not listed as a survey item, and had not been formally examined by TC as part of the continuous hull survey regime since the vessel was brought under Canadian registry in 1983. TC did not conduct a boat and fire drill as required at annual inspections, nor were the crew's certificates examined. The inspector had no tanker experience or training, did not possess a petroleum tanker endorsement, nor had he taken a tanker safety course. Ultramar also inspected the vessel in May 1997 to determine if she was suitable for charter. The cargo-pumping system was inspected at the time using the Oil Companies International Marine Forum survey form. However, the type of cargo pump priming/stripping system, or defects to the system, were not noted. The crew's certificates were not sighted. The vessel was accepted for charter by Ultramar. 1.16 Use of the Government Wharf by Passenger Ferries and Tankers On at least 20 occasions a year, the PETROLAB was present at the dock while the Quebec North Shore ferry NORTHERN PRINCESS embarked and disembarked passengers. The ferry's published schedule shows that she departs St. Barbe at 0800, 1230, and 1700, and would have been alongside the dock for 30 to 45 minutes before each departure on the day of the explosion. Besides a barricade and a fire extinguisher at the end of the government wharf, no special precautions were taken when the passenger vessel docked. 1.17 Fire Safety in Canadian Ports and Harbours In December 1994, during the unloading of a cargo of rock phosphate in the port of Belledune, N.B., a fire broke out in the conveyor belt system of the bulk carrier AMBASSADOR (TSB Report No. M94M0057). The combined efforts of the ship's crew and several shore-based fire departments were required to bring the fire under control before it was fully extinguished, some 28 hours later. The port of Belledune is a divisional port administered by Canada Ports Corporation. In Canadian ports and harbours, the responsibility for risk assessment and emergency plans generally rests with the local harbour master or port official whilst the firefighting is provided by the local fire department. In Canada, none of the ports have a dedicated or trained marine fire brigade. Concerned that many municipal fire departments may not have properly trained personnel to fight shipboard fires, the Board made three recommendations: The Department of Transport [should] conduct a special audit of firefighting facilities at Canadian ports and harbours under its jurisdiction to ensure that an adequate year-round capability exists to contain shipboard fires. The Department of Transport [should], in collaboration with ports and harbour authorities, take measures to ensure that shore-based fire brigades expected to support on-board firefighting receive appropriate training. The Department of Transport [should] take appropriate measures to ensure that on-board firefighting capabilities of vessels in Canadian ports and harbours are functional and readily available during cold weather operations. In its response, TC indicated that the Canadian Association of Fire Chiefs (CAFC) is responsible for the standards and training of shore-based fire brigades.[10] The majority of public harbours have only a local volunteer force to fight small fires and their training generally does not include entering and fighting fires in restricted places. TC also indicated that at present there are no legislated requirements for public harbours and ports to enter into firefighting activities aboard vessels. Subsequently, in May 1997, the CAFC forwarded a questionnaire to selected municipalities to determine their firefighting capabilities and the type and extent of assistance that could be called upon by operators of marine terminals in the event of a fire on board a vessel in port. Since the AMBASSADOR occurrence, there have been three occurrences in which municipal fire departments were involved in fighting shipboard fires (TSB Report Nos. M97W0035, M97W0044, and M97W0194). 1.18 Safety and Emergency Preparedness in Canadian Ports Pursuant to the Public Harbour and Port Facilities Act, TC, Harbours and Ports (HP) is responsible for the administration and safety of approximately 549 small ports and harbours in Canada. Under the Canada Ports Corporation Act, Ports Canada oversees 14 of the largest and more important commercial ports, such as those at Vancouver and Montreal. There are also nine harbour commissions with their own enabling legislation. The Department of Fisheries and Oceans is responsible for 2,000 small recreational and fishing harbours. In December 1995 the Minister of Transport announced the new National Marine Policy, and early in 1996 introduced the Canada Marine Act in the House of Commons. One of the objectives of the National Marine Policy is the commercialization of the 572 public ports and harbours. While the larger, more-profitable ports will become the responsibility of Canada Port Authorities (CPA), a second category of smaller regional and local ports will be divested to the provinces and municipalities. The Emergency Preparedness Act, which became effective 1 October 1988, bestows a government-wide mandate on all federal departments and agencies to develop and coordinate programs to deal with unforeseen and potentially disastrous events, including emergencies such as fire, explosions, chemical spills, etc., in Canadian ports and harbours. Emergency preparedness involves three elements: assessing the risks associated with the operation, emergency planning to deal with the risk identified, and training and practice to effectively execute the plan. There has not been any evaluation of risks at regional or local ports across Canada to prepare emergency plans. Today, only the larger CPA have the physical and human resources to prepare for emergencies. Small local ports administered by TC and DFO--or those divested to the provinces or municipalities--do not have adequate resources to ensure emergency preparedness. As for the divested ports, it appears that the onus is on the new owner/operator to ensure that they have what they need to operate safely and remain an ongoing viable entity. TC does not maintain physical or regulatory supervision over divested sites/facilities to ensure compliance by the new entity with the safety provisions of acts and regulations administered under its authority. As such, there are no provisions for enforcement of safety measures nor for safety audits of divested facilities. 1.19 Guidelines on Risk Assessment and Emergency Plans for Ports Internationally, the United Nations Environment Programme (UNEP) has developed a process for responding to technological accidents, called Awareness and Preparedness for Emergencies at Local Level (APELL) . Two basic approaches are used: first, to increase knowledge in the community about possible risks and hazards in the area and, second, to develop a coordinated emergency response plan. In 1994-95 the International Maritime Organization (IMO) and the UNEP developed a joint publication for port users and operators on how to apply APELL in ports. The publication addresses port facilities' unique hazardous situations and activities that pose risks to persons, property and the environment. In February 1995 a group of international experts gathered in London to develop and review the joint UNEP/IMO document Guidance on Application of APELL in Ports. Documents like this, and other publications prepared by the Emergency Preparedness College, provide adequate guidance to port management for conducting risk assessment and for the development of emergency plans in local ports and harbours.